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Nayana Dubier Professor Wolcott November 15, 2013 Literature Review on Gestational Diabetes Mellitus Researchers in the Obstetrics and

Gynecology field have found that there has been an increase in the amount of pregnant women who are obese (Aviram et al 2011; Ornoy 2011). In recent medical journals, researchers discuss studies they conducted in which they tested to see if there was a direct link between excess gestational weight gain, maternal overweight/obesity, and Gestational Diabetes Mellitus (GDM). According to the American Journal of Public Health and the American College of Obstetricians and Gynecologists, Gestational Diabetes Mellitus is defined as “carbohydrate intolerance leading to hyperglycemia with onset or first recognition during pregnancy” (Shin et al e65). Researchers began by conducting studies to help determine the possible factors that would led a pregnant woman to develop Gestational Diabetes and how this medical issue would affect the infant. Some researchers found that there was a link between excess gestational weight gain, maternal overweight/obesity and Gestational Diabetes (Aviram et al 2011; Chu et al 2007; Hedderson et al 2010; O’Dwyer et al 2012; Yogev et al 2009). While other researchers conducted studies on the serious effects that GDM have on the mothers and their infants (Black et al 2013; Boney et al 2005; Hadar et al 2009; Olmos et al 2012; Ornoy 2011; Roman et al 2011). Also, a couple of other medical researchers discuss different methods to help reduce the chances of obtaining GDM (Chu et al 2007; Ghandi et al 2011; Hadar et al 2009; Joy et al 2012; Landon et al 2011). The study of GDM is a crucial topic since not only does Gestational Diabetes affects the mothers health during and after her pregnancy but GDM also affects the infants health during both and could lead to future complications later in his or her life.

The link between Obesity and Gestational Diabetes By conducting tests and collecting previous studies, researchers found that there was a link between Gestational Diabetes Mellitus and obesity in pregnant women they found that women who were overweight/obese had a higher chance of developing GDM (Aviram et al 2011, Chu et al 2007, Hedderson et al 2010, O’Dwyer et al 2012, and Yogev et al 2009). Researchers like Aviram et al 2011 began by collecting ample amounts of studies, done by previous researchers, on the rise in obesity and its link to GDM. From the data collected by the researchers, it shows that between 18.5 to 38.3 percent of pregnant women are obese (Aviram et al 2011). The authors found that there was a 2-10 fold increase in women with gestational diabetes who were obese (Aviram et al 2011).Similarly, medical researchers from the American Diabetes Association collected information from twenty studies and comprised it into a meta-analysis. The researchers’ findings showed that there was a link “between high maternal weight and high risk of GDM” (Chu et al 2007). Medical researchers from Kaiser Permanente Medical Care Program of Northern California created a study to test the theory that the increase in obesity is linked to the increase in GDM (Hedderson et al 2010). The study included 345 women with GDM and 800 women in the controlled group who had given birth between January 1, 1996 and June 30, 1998. During these women’s pregnancy, they were screened for GDM at 24-28 weeks of gestation. The researchers found that “the link between gestational weight gain and the risk of GDM was mainly attributable to excessive weight gain in the first trimester” (Hedderson et al 2010). The authors concluded that “the risk of GDM increased with increasing rates of gestational weight gain” (Hedderson et al 2010). Medical researchers from the University College of Dublin Centre for Human Reproduction created a study where they screened moderate and severe obese

pregnant women for gestational diabetes (O’ Dwyer et al 2012). The study included 92 white European women with a BMI greater than² who were administered an oral glucose tolerance test twice: once at 20 weeks gestation and then another one at 28 weeks gestation (O’Dwyer et al 2012). The results revealed that “nearly one in five women with moderate or severe obesity had an abnormal OGTT when screened for GDM” (O’Dwyer et al 2012). The medical researchers also studied twenty previous studies conducted on GDM and found that, “the risk of developing GDM was about two, four and eight times higher among overweight, obese, and severely obese women respectively” (O’ Dwyer et al 2012). Medical researchers from Tel Aviv University discuss in a peer-reviewed review about the connection between obesity and gestational pregnancy outcomes (Yogev et al 2009). The medical researchers found that when studying previous studies conducted that, “GDM, especially in combination with pre-pregnancy obesity, predicts a subsequent syndrome of high cardiovascular risk” (Yogev et al 2009). In conclusion, the medical researchers found that, “obesity is associated with GDM which showed an increase in adverse pregnancy outcomes” (Yogev et al 2009). Effects on Mother and Infant While some medical researchers focused on finding evidence that linked obesity and GDM, other medical researchers focused on the effects that GDM and obesity would have on the mother and infant like an increase in infants with fetal overgrowth, metabolic Syndrome, becoming obese later in life, future insulin resistance, macrosomia, and composite neonatal complications (Black et al 2013; Boney et al 2005; Hadar et al 2009; Olmos et al 2012; Ornoy et al 2011; Roman et al 2011). Medical researchers, authors in Diabetes Care, created a study to evaluate whether prepregnancy overweight and obesity among women with or without GDM affect fetal overgrowth (Black et al 2013). In their study, they created six groups: 1) normal

weight, no GDM 2) normal weight, GDM 3) overweight, no GDM 4) overweight, GDM 5) obese, no GDM and 6) obese, GDM ( Black et al 2013). They found that, “out of these with GDM, 1443 (76.3 %) were overweight or obese and of the 76.3 % women about 23.3 % accounted for having large-age- gestational infants (Black et al 2013). The authors concluded that “by increasing gestational weight gain that the rate of LGA in infants increased” (Black et al 2013). In a similar study, medical researchers from the Department of Pediatrics measured 6,7,8,9, and 11 year olds’ glucose tolerance, weight, insulin and high-lipoprotein cholesterol levels to determine if they were at risk for Metabolic Syndrome (Boney et al 2005). The researchers divided the children into four groups: LGA offspring of mothers without GDM 2) LGA offspring of mothers with GDM 3) AGA (appropriate-for-gestational age offspring of mothers without GDM 4) AGA offspring with mothers with GDM (Boney et al 2005). The authors concluded that “LGA offspring of diabetic mothers were at significant risk of developing Metabolic Syndrome in childhood” (Boney et al 2005). Medical doctors from the Helen

Schneider Hospital for Women in Petah-Tiqva, Israel, state the statistics taken from previous studies on the effects that mothers with GDM and their infants might encounter. The authors found that “prepregnancy obesity and diabetes independently increases the risk of cesarean section deliveries and increases the risk of infants being born with macrosomia (Hadar et al 2009). The authors also found an increase in stillbirths, abnormal fetal growth, and birth trauma to infants born to mothers with GDM (Hadar et al 2009). Medical and engineering researchers from Pontificia Universidad Catolica de Chile, conducted a study where they studied 251 GDM pregnancies and separated the mothers into two groups: the non-overweight group and overweight group. The researchers found that “macrosomia rates were 10.4% in the nonoverweight group and 24.6% in the overweight group” (Olmos et al 2012). Asher Ornoy, a

medical researcher from Hebrew University Hadassah Medical School, collected studies done by fellow researchers on the effects that obesity has on pregnancy complications and the links between obesity and gestational diabetes (Ornoy 2011). Ornoy found that “children with mothers who had GDM had a higher rate of overweight/obesity during childhood and adolescence compared to children with mothers who did not have GDM” (Ornoy 2011). Medical researchers from Maternal Fetal Medicine Associates and Alere Women’s and Children’s Health, created a study in which they collected 3789 patients from July 2000 and July 2009 what were diagnosed with GDM (Roman et al 2011). The researchers broke the women into five groups: underweight, normal weight, overweight, obese and, morbidly obese. The authors concluded that there was an “increase in hostile maternal and neonatal outcomes with obese women when compared to the non-obese women” (Roman et al 2011). Possible Treatments Medical researchers that found that there was a link between obesity and Gestational Diabetes Mellitus suggested different methods in order to lower the percent of overweight pregnant mothers with GDM (Chu et al 2007; Ghandi et al 2011; Hadar et al 2009; Joy et al 2012; Landon et al 2011). Most of the researchers came to the conclusion that mothers must maintain a healthy nutritional diet and physical exercise in order to lower chances of developing GDM (Chu et al 2007, Hadar et al 2009; Landon et al 2011). While other medical researchers found that in addition to a healthy diet and exercise that insulin injects and early screening could help lower the rates of mothers with GDM (Ghandi et al 2011; Joy et al 2012). Conclusion There is a need for more studies created that study the possible causes and factors of Gestational Diabetes Mellitus. In the past there was not much need for studies on Gestational

Diabetes Mellitus since the cases were far and between. However, there has been a recent increase in cases with pregnant women with GDM who are obese. More studies done on this subject matter would help future researchers determine different treatment options for the mothers and infants who are affected by GDM. Research Proposal In recent years, there has been an increase in the number of cases of pregnant women with Gestational Diabetes Mellitus. According to the American Journal of Public Health and the American College of Obstetricians and Gynecologists, Gestational Diabetes Mellitus is defined as “ carbohydrate intolerance leading to hyperglycemia with onset or first recognition during pregnancy” (Shin et al e65). Researchers found cases in which Gestational Diabetes Mellitus was found in both pregnant women who had a normal BMI weight and women who are categorized as overweight/obese. However, there was a higher amount of cases with women who were overweight/ obese and had GDM. More studies need to be conducted in order to find possible causes and factors of Gestational Diabetes Mellitus in order to create more treatment options for mothers and infants who are affected by GDM. Many possible studies can be created in order to One possible study could begin by gathering about 500 obese pregnant women in their 20 weeks stage in their pregnancy who have not developed GDM and begin them on a strict dietary and exercise plan. The women will be between the ages of 27-34 years old and the test will be conducted in a controlled environment such as UF Health Shands Hospital in Gainesville, Florida. Before the women are put onto the dietary and exercise plan the researchers would determine their chances of developing GDM. Then, the women would begin their dietary and exercise plan for about three months. During the half way point of about the three months, researchers would determine again the overweight/ obese pregnant women’s chances of developing GDM. Then researchers could do a comparison to the first tests conducted and see if

there was a lowering of GDM after the dietary and exercise plan. From the results, researchers could create better treatment plans for overweight/ obese women in order to lower their chances of developing GDM.

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